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15110007 CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 20975 VALLEY GREEN DR APT 240 CONTRACTOR:KORET VC I LP PERMIT NO:15110007 OWNER'S NAME: KORET VC I LP 611 FRONT ST DATE ISSUED:11/02/2015 OWNER'S PHONE: 4082530200 SAN FRANCISCO,CA 94111 PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL ❑ COMMERCIAL ❑ License Class Lie.# 117�,Ar . Contractor Date I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000)of Division 3 of the Business&Professions Code and that my license is in full force and effect. I hereby affirm under penalty of perjury one of the following two declarations: I have and will maintain a certificate of consent to self-insure for Worker's Compensation,as provided for by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. Sq.Ft Floor Area: Valuation:$500 I have and will maintain Worker's Compensation Insurance,as provided for by Section 3700 of the Labor Code,for the performance of the work for which this APN Number:32609041.240 Occupancy Type: permit is issued. APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED correct.I agree to comply with all city and county ordinances and state laws relating WITHIN 180 DAYS OF PERMIT ISSUANCE OR to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We)agree to save 180 DAYS FROM LAST CALLED INSPECTION. indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the granting granting of this permit. Additionally,the applicant understands and will comply Issued by:- �, /✓ G Date: // with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. RE-ROOFS: Signature Date All roofs shall be inspected prior to any roofing material being installed.If a roof is installed without first obtaining an inspection,I agree to remove all new materials for inspection. ❑ OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for one of Signature of Applicant: Date: the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER 1,as owner of the property,or my employees with wages as their sole compensation, will do the work,and the structure is not intended or offered for sale(Sec.7044, Business&Professions Code) 1,as owner of the property,am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE construct the project(Sec.7044,Business&Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the California Health&Safety Code,Sections 25505,25533,and 25534. 1 will I hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the declarations: Health&Safety Code,Section 25532(a)should I store or handle hazardous I have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should I use equipment or devices which emit hazardous Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as defined by the Bay Area Air Quality Management District I performance of the work for which this permit is issued. will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Se ns 25505,2553��a25534. Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. Owner or authorized ag t: Date: "_1 I certify that in the performance of the work for which this permit is issued,I shall not employ any person in any manner so as to become subject to the Worker's Compensation laws of California. If,after making this certificate of exemption,I CONSTRUCTION LENDING AGENCY become subject to the Worker's Compensation provisions of the Labor Code,I must I hereby affirm that there is a construction lending agency for the performance of forthwith comply with such provisions or this permit shall be deemed revoked. work's for which this permit is issued(Sec.3097,Civ C.) Lender's Name APPLICANT CERTIFICATION Lender's Address I certify that I have read this application and state that the above information is correct.I agree to comply with all city and county ordinances and state laws relating to building construction,and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes.(We)agree to save ARCHITECT'S DECLARATION indemnify and keep harmless the City of Cupertino against liabilities,judgments, costs,and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records. granting of this permit.Additionally,the applicant understands and will comply with all non- ' ource regulations er the Cupertino Municipal Code,Section Licensed Professional 9.18. Sign re Date �� GENERALPERMIT APPLICA M COMMUNITY DEVELOPMENT DEPARTMENT-2j 10300 TORRE AVENUE•CUPERTINO, CA 95014-3255 ING DIVISION MEF 1 CUP RTINO (408)777-3228•FAX(408)777-3333•buildin cu ertino.orp /5 �o ll � 7 PLUMBING ❑MECHANICAL PROJECT ADDRESS L•LECTRICALD MISCELLANEOUS < APN 11 OWNERNAME / d rxolvE I ��•_ E-MAIL STREET ADDRESS �� rQd >L�r CITY, ATE Zip. AX !. CONTACT NAME� � •'� L� <�-, -\ (�. G PHD E-MAIL STRL•ET ADDRESS 7 COY ZIP 'la/ G FAX i oWNE�t ❑ owNER-ntm nER ❑ OWNERAGExr ❑ i CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHr ECT ❑ENGor ❑ DEv�OPER ❑TENANT CONTRACTOR NAME �' J y LICENSENUMBER LICETISETYPE 3 BUS.LIC 8 ,3 CO PANY NAMI: E-MAIL FAX STR.EETADDRESS STATE,ZIP I ARCHITECTIENGMEER NAME LICENSENUhIBFR BUS.LIC 9 COMPANY NAME E-MAIL STILET'ADDRESS FAX CITY.STATE,ZIP PHONE USE OF ❑SFD orDU?LEX LTI-FAhW Y FROJECTIN WMDLANO ❑ YES PROJECT IN DUII�It1G ❑COM1rtERC1AL ❑YES IS THE BLDG AN ------ _URBAN IIrtERFACE AREA NO FLOOD ZONE ❑YES DL•SCRIPTION OF WORK " NO EICHLER HON127 NO - i} D e TOTAL VALUATION. _4 ,1 ,_-•:-�•...•__- , BY mY signature below ,�: I certify to each of the following. I am t e property owner or authorized agent to act on the property owner's behalf�I`havc read this ' application and the information I have provided is correct. I haveauthorize read the ascription Of Work and verify it is accurate. I agree to comply with all applicabic local ordinances and state laves relating to buli3ing construct' n. I resentatives of Cupertino to enter the above-idcntifi A Signature of Applicant/Agent: tee' yl %� j cd PrOpertY for inspection pu�oscs. C Date_ SUPPLEMENT'AL INFORMATION RED C - ��o�ic;~v`sEbrriii<� -;�s..• ?�.li... m ; _ •t=t�-�-.-,j i�J•.� :'�\.r�' {;EXPRESS•=�:>o-__-=rA::;:�."_ t±: "D - `i-� .: ":i Iii.'-!."1=r::'�:�-•" �`_� AZPA!fisc,4pp_201 J.docrevised 06/21/11 CITY OF CUPERTINO FEE ESTIMATOR- BUILDING DIVISION ADDRESS:, j. �-1/ALLEY GREEN DR,,2,< y DATE:ll—,17 z)_i REVIEWED BY: MELISSA APN: 32Z, BP#: 'VALUATION: $500 R�PERMITTYPE: Mechanical Permit PLAN CHECK TYPE: Alteration /Addition / Repair PRIMARY Multi-Family Dwelling Building is PENTAMATION USE: >3 Stories Q Yes Q No PERTYPE: 1 RMAP1 WORK UNIT,9471�, .NSTALL NEW WASHER/DRYER HOOKUPS , SCOPE APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES Other Appliance/Equip 18APPLOT 2 # $144 TOTALS: $144.00 Mech.Plan Check0.0 hrs $0.00 ::n;1.>. Plat,Ci1cxG I.lec.Pian l:`{uck Mech. Permit Fee: IMPERMIT Flumb. Permit Fee: Elec. Permit ree: Other Mech. Insp. 0.0 hrs $48.00 Plumb ImpF-1 7 Iliher Elec. Insp. !trap. PC, Phimh. hasp. Fee: Elec.Insp. Plea NOTE: This estimate does not include fees due to other Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer District,School District,etc.). Theseees are based on the prelimina information available and are only an estimate. Contact the De t or addn'1 info. FEE ITEMS (Fee Resolution 11-053 Eff 7,1'13) FEE QTY/FEE MISC ITEMS Piun Check Fere: Suppl. PC Fee PME Plan Check: $0.00 Perinit Feer: ttppl. Ins])Fee PME Unit Fee: $144.00 PME Permit Fee: $48.00 (;ott.slruction 1,41X: Administrative Fee: 1ADMIN $45.00 Work Without Permit? O Yes (j) No $0.00 ldt,uneecl Planning Fees: Travel Documentation Fee: ITRA VDOC $48.00 i Strong Motion Fee: IBSEISMICR $0.50 Select an Administrative Item Bldg Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: $286.50 $0.00 TOTAL FEE: $286.50 Revised: 07/02/2015 OWNER-BUILDER DISCLOSURE FORM COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION 10300 TORRE AVENUE•CUPERTINO, CA 950143255 zi CUPERTINO (408)777-3228• FAX{408)777-3333- buildino(a)cuoertino ora Dear Property Owner(s): An application for a building permit has been submitted in your name listing yourself as the builder of the property specified at: p rty improvements speci SiTE ADDRESS , ice" APN BP# OWNER NAME � INNER ADDRESS n 7 DESCRIPTION OF WORK: f V tl;,- l We are providing you with an Owner-Builder Acknowledgment and Information Verification Form to make you aware of Your responsibilities and possible risk you may incur by having this permit issued in your name as the Owner-Builder. We will not issue a building permit until you have read, initialed your understanding of each provision, signed, and returned this form to us at our official address indicated. An agentof the owner cannot execute this notice unless you, the property owner, obtain the prior approval of the permitting authority. OWNER'S ACKNOWLEDGMENT AND VERIFICATION OF INFORMATION (DiRECTiONS_Please read and initial each statement below to signify you understand or verify this information.) TI -1. I understand a frequent practice of unlicensed persons is to have Builder"building permit that erroneously implies that the roe a e the property owner obtain an providingner is s or her wn lab"Owner- personally. 1, as an Owner-Builder, may be held liable and suubject o serio sfinan I al k for any njurriitained by r sus material an unlicensed person and his or her employees while working on my property. M homeowners insurance may not provide coverage for those injuries. I am willfully acting as an Owner-Builder and m aware of the limits of my insurance coverage for injuries to workers on my property. V�2. I understand building permits are not required to be signed by prperty the construction and are not hiring a licensed Contractor to assume this e spons b iy unless they are responsible for J V 3. 1 understand as an"Owner-Builder" I am the responsible party of record on the permit. i understand protect myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his orhat her may name instead of my own. 7 �4. 1 understand Contractors are required by law to be licensed and bonded in California and to lis numbers on permits and contracts. t their license 5. 1 understand if I employ or otherviiise engage any persons, other than California licensed Contractors, and the total value Of my construction is at least five hundred dollars ($500), including labor and materials, 1 may be considered an "employer"under state and federal law. uJ6. I understand if I am considered an "employer' under state and federal ! aw, I must reisterthe federal government, withhold payroll taxes, provide workers' compensation disability i su ance, a dtcontributteetond unemployment compensation for each "employee." I also understand my failure to abide by these laws may subject me to serious financial risk. understand under California Contractors'State License Law, an Owner-Bu" ly residential structures cannot legally build them with the intent to offer them for sale,iunle s all er who bwork isuilds performed by licensed subcontractors and the number of structures does not exceed four within any calendar year, or all of the work is performed under contract with a licensed general building Contractor. 'J 1`/& 1 understand as an Owner-Builder if I sell the property for which this permit is issued, 1 may be held liable for any financial or personal injuries sustained by any subsequent owner(s) that result from any latent construction defects in the workmanship or materials. Oi+,nefBuildeiFonn_2010.doc revised 04/14/10 A-9-- 1 ulruerstand 1 may obtain more information regarding my obligations as an "employer" from the Intern Revenue Service, the United States Small Business Administration, the California Department al and the California Division of industrial Accidents. I also understand i may contact the California Contract License Board (CSLB) at 1-800-321-CSLB (2752) or www.cslb.ca.gov far more information of Benefit Payments, contractors. ors' State on about licensed 10. 1 am aware of and consent to an Owner-Builder building am the party legally and financially responsible for proposed constructionpait Ptivty at for lthe site address lin my name, and s ted a above.that . d above, 11. i agree that, as the party legally and financially responsible for this proposed construction activit , I will abide by all applicable laws and requirements that govern Owner Builders as well as employers. y )�1-/12. I agree to notify the issuer of this form immediately information I have provided on this form.Licensed contractors are regulated byelaws des r nchaed toes to any of the protect the pub You contract with someone who does not have a license, the Contractors'State License Board may be unable tolic. if assist you with any financial loss you may sustain as a result of a complaint.Your only remedy against unlicensed Contractors may be in civil court. it is also important for you to understand that if an unlicensed Contractor or employee of that individual or firm is injured while working on your property, you may be held liable for damages. If You obtain a permit as Owner-Builder and wish to hire Contractors, you will be responsible for verifying whether or not those Contractors are properly licensed and the status of their workers' compensation insurance coverage. CONSTRUCTION LENDING AGENCY (DIRECTIONS:Please complete the following construction lending agency information.) I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Sec 3097 Civ.) Lender Name: Lender Address: Before a building permit can be issued,this form must be completed and signed by the property owner and returned to the agency responsible for issuing the permit. Note:A co PY of the property form notarization, or other verification acceptable to the cif . bownersver's license, to verifythe property owners sina ma e required to be prese tedd when'ther permit s slued ' Property Owner's Signature: Date: -------------------------------------------------------------------- ---------------------------------------------- - (NOTE. The following Authorization Form is required to be completed by the property owner only when - an ----------- --------------- agent of the property owner to apply for a construction permit for the Owner-Builder). designating AUTHORIZATION OF AGENT TO ACT ON PROpERTY OWNER'S BEHALF Excluding the Notice to Property Owner, the execution of which 1 understand is m y personal ty,authorize the following person(s) to act as my agent(s) to apply for, sign, and file he document necesresponsiblsarylto orbtaheebYn an Owner-Builder Permit for my project. Scope of Construction Project(or Description of Work): Project Location or Address: Name of Authorized Aaent: Tel No Address of Authorized Agent: i declare under penalty of perjury that I am the property owner for the address listed above and 1 personally filled out the above information and certify its accuracy. Note:A copy of the property owner's driver's license, form notarization, or other verification acceptable to the city may be required to be presented when the permit is issued to verify the property owner's signature. Property Owner's Signature: Date: Di,:nerBuildeJFoi7??_2OIO.doc revised 04/14110